Sunday, March 1, 2015

Benzodiazepines: Helpful or Harmful?

The mere thought of climbing into a car sends Jenn spiraling into a state of agitation and fear.

Jenn, a 30-year-old freelance book editor who lives in North Carolina, survived two near-fatal car accidents as a teenager. Since then, she’s battled post-traumatic stress disorder and panic attacks. She has visited a therapist, and she regularly takes Zoloft, a medication that treats depression, anxiety and other conditions. But the only thing that truly quells her nerves before sliding into a vehicle’s passenger seat, she says, is Valium.

“I notice that once I go ahead and take it, I feel so much better — like I can finally relax,” she says. “Sometimes that makes all the difference in the world.”

Valium is a medication that’s part of a larger class of drugs called benzodiazepines.

Benzodiazepines are commonly prescribed for anxiety and agitation. They can also be used for insomnia, seizures and alcohol withdrawal.

Some types of benzodiazepines are instantly recognizable; Ativan and Xanax, for example, have infiltrated popular culture and are now colloquially considered “quick fixes” for everything from poor sleep to panic disorders. But other forms include – but aren’t limited to – the drugs Klonopin and Valium.

Benzodiazepines are some of the most common medications in the world; a recent study sponsored by the National Institutes of Health found that about 1 in 20 adults received a prescription for them in 2008. They’re extremely effective for patients like Jennm, who have crippling anxiety. Unlike medications like selective-serotonin reuptake inhibitors, which take several weeks to reach full efficacy, benzodiazepines work almost immediately. They can also be good for treating chronic anxiety in patients who have adverse reactions to SSRIs and similar medicines.

The Drawbacks?

Benzodiazepines can be habit-forming. And they carry a host of dangerous side effects — including impaired cognition and mobility in older individuals, and potentially life-threatening withdrawal symptoms in people with severe addictions.

A study sponsored by the National Institute of Mental Health recently linked long-term use of benzodiazepines to a heightened risk for Alzheimer’s. And data from the Centers for Disease Control and Prevention showed that benzodiazepines, along with opioid pain relievers, are the prescription drugs most often responsible for emergency department visits and drug-related deaths.

So are benzodiazepines helpful or dangerous? Like most pharmaceutical drugs, experts say, they’re a mixed bag. Despite studies suggesting that physicians over-prescribe them, even those in the medical community tend to disagree on whether the benefits of benzodiazepines outweigh the risks. For every doctor who writes a prescription for Xanax, there’s another who refuses to do so, says Jerrold Rosenbaum, chief of psychiatry at Massachusetts General Hospital.

“It’s amazing how polarizing the conversation gets,” Rosenbaum says. “There is a constituency that views [benzodiazepines] as evil and harmful; they tend to come out of the substance use disorder community. They’re not perfect drugs, but they do work for conditions for which nothing else [is as effective].”

However, experts say most physicians agree on the following guidelines – independent of whether or not they themselves prescribe benzodiazepines.

Benzodiazepines can be safe for short-term use. “Benzodiazapines are very effective, particularly in the short term, for the treatment of acute anxiety and insomnia,” says Larissa Mooney, an assistant professor of psychiatry and director of the Addiction Medicine Clinic at the University of California-Los Angeles. “They calm people down, and they help people fall asleep and stay asleep.”

Most doctors say benzodiazepines should not be prescribed for more than a few weeks. The body slowly builds up a dependency to the pills, which can be averted by not taking them for an extended duration. Patients should also make sure to follow their doctor’s dosage instructions, and to slowly taper off the medication instead of stopping cold turkey.

In some cases, though, long-term use of benzodiazepines can be acceptable, Mooney says.

“There are a subset of people who seem to respond very well to long-term benzodiazepines,” she says. “They may be maintained on a low dose and never need anything higher — meaning they don’t develop a tolerance. They may be intolerant to other classes of medications. And it seems to augment their treatment for anxiety.”

All of the above are true for Jenn, who has sporadically taken Valium over the years. She sticks to a low dosage, goes periods of time without taking the medicine and says she’s never felt any physical side effects. She’s also had bad reactions to other antianxiety drugs; Valium is the only medicine she’s taken that hasn’t produced physical side effects. And while Zoloft helps her anxiety, Valium is more effective at halting her nightmares and panic attacks.

Not a cure-all

Many people with panic disorder or acute anxiety use benzodiazepines as a first-line method of treatment until they’re able to find another coping mechanism. But they might also have underlying issues that contribute to their anxiety, Rosenbaum says. These problems might be best addressed by tackling life stressors, taking an antidepressant that helps with anxiety or trying cognitive-behavioral therapy.

Certain people should not take benzodiazepines.

People with a history of alcoholism or drug addiction are advised against taking benzodiazepines. Similarly, elderly people face an increased risk of falls, cognitive disturbance, sleep apnea and a potentially heightened chance of dementia, says Charles Reynolds, a professor of geriatric psychiatry at the University of Pittsburgh School of Medicine.

However, he says, certain factors that often appear with aging — for instance, bereavement, insomnia and low-grade depression complicated by anxiety — mean benzodiazepines “do have a place in the management of emotional distress in older adults.” In these cases, he says their best bet is a short-acting benzodiazepine prescribed for a limited duration.

And it goes without saying, he adds, that anyone taking benzodiazepines should avoid depressants such as alcohol or opioids. Doctors should carefully monitor patients’ use of benzodiazepines.

“In most cases of benzodiazepine dependence, addiction begins with a legitimate prescription,” says Tiffany Jones-Rouse, a licensed social worker and substance abuse counselor based in the Baltimore-District of Columbia metro area. “Folks seek intervention for a variety of conditions, from muscle spasms to chronic anxiety disorders, and they’re often issued a prescription for Xanax, Valium, Klonazepam, Ativan or another tranquilizer.”

These drugs, she says, can be beneficial for people who have never demonstrated drug or alcohol dependence. In this case, their dosage should always be time-limited and closely monitored by a physician who addresses the potential for addiction.

The problem, Jones-Rouse says, is that while many physicians impose prescription time limits and address the risks and side effects, others might not. Over time, a patient will sometimes develop a tolerance toward the benzodiazepines. Their negative symptoms will return, and they will either request a larger dosage from their doctors, buy the medicine illegally or turn to another substance, like alcohol.

In certain cases, Jones-Rouse adds, people don’t recognize that they’re dependent until they make the decision to stop taking the medication. They’ll quickly find that they experience uncomfortable withdrawal symptoms such as mood swings, agitation and irritability, and changes in appetite and sleep patterns, among others.

In worst-case scenarios, unmonitored benzodiazepine withdrawal can lead to stroke, seizures and heart attacks. And benzodiazepines, when combined with other drugs, can result in overdose and death.

It’s possible to safely withdraw from benzodiazepines, even after extended use or abuse.

According to Jones-Rouse, hospitals and treatment programs provide medical monitoring for the detoxification phase. Therapists, social workers and psychologists trained in dealing with substance abuse can provide longer-term psychological care. And public support programs such as the 12-step programs Narcotics Anonymous and Chemically Dependents Anonymous provide a social support network that aids in recovery.